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Radiology Prior Authorization and Notification

These programs support the consistent use of evidence-based, professional guidelines for diagnostic imaging procedures. They help reduce risks to patients and improve the quality, safety and appropriate use of imaging procedures.

Basic Requirements and Process

Notification and prior authorization may be required for these advanced outpatient imaging procedures:

  • CT scans*
  • MRIs*
  • MRAs*
  • PET scans
  • Nuclear medicine studies, including nuclear cardiology

Authorization is not required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay.

*Please refer to the CPT Code List within the Specific Radiology Programs section below for product specific procedure requirements.

These requirements apply to all providers subject to the UnitedHealthcare Administrative Guide. To review the complete protocol, please refer to the Outpatient Radiology Notification/Prior Authorization Protocol section in that guide.

For further information on related imaging policies, see Imaging Accreditation.

Specific Radiology Programs

Click the "+" sign next to a title to see more information about that program.

The following Commercial resource materials are inclusive of the UnitedHealthcare River Valley and NHP membership.

When you notify us of a planned service that is subject to the protocol, we’ll conduct a clinical review to determine if the service is medically necessary and covered, and will let you know our decision.

If the member's benefit plan does not require a clinical review and the service does not meet clinical guidelines, or if additional information is needed, we’ll let you know if you need to have a physician-to-physician discussion.

This program is effective in Arizona, California, Delaware, Florida, Iowa, Louisiana, Maryland, Massachusetts, Mississippi, Missouri, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington and Wisconsin.

Resources materials are included in the Commercial tab above.

Resources materials are included in the Commercial tab above.

For information about UnitedHealthcare Oxford policies, please refer to the UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies page. This page has all UnitedHealthcare Oxford clinical, administrative and reimbursement policies, including the following commonly referenced imaging policies:

  • Breast Imaging for Screening and Diagnostic Cancer
  • Credentialing Guidelines: Participation in the eviCore Healthcare Network
  • Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy
  • Obstetrical Ultrasonography
  • Oxford’s Outpatient Imaging Self-Referral Policy
  • Radiology Procedures Requiring Precertification for eviCore Healthcare Arrangement
  • Radiopharmaceuticals and Contrast Media